Diagnosis of Mallory-Weiss lesions. A common cause of upper gastrointestinal bleeding

Mallory-Weiss Syndrome: Possible Link to Water Immersion and Subsequent Air Flight

Mallory-Weiss Syndrome (MWS) lesions account for up to 15 per cent of upper gastrointestinal bleeding episodes. Typically these lesions present as a consequence of vomiting that is often associated with alcoholism. Recently other conditions such as pregnancy, migraine, hiatal hernia, gastric ulcer, biliary disease, and various medications have been associated with MWS. We report on a 32-year-old male who developed a MSW lesion after a prolonged period of swimming followed by an extended commercial airplane flight. The hemodynamic changes associated with swimming (increased central distribution of blood volume) and the pressure changes in commercial aircraft (a reduction of 0.3 atmospheres of pressure) are discussed. We conclude that the combination of these factors contributed to the development of a MWS lesion and gastrointestinal bleeding in this patient. We recommend that both air travel and athletic activities be considered as possible contributing factors in the evaluation of the cause of new-onset gastrointestinal bleeding.

Nonvariceal upper gastrointestinal bleeding

The approach to nonvariceal UGI bleeding has been reviewed. Therapeutic endoscopy has been shown to be superior to medical therapy in patients with an actively bleeding ulcer and those at high risk of rebleeding. Of endoscopic therapies available to the GI endoscopist, multipolar electrocoagulation, heater probe, and injection therapy are comparable in efficacy and safety.

The current role of endoscopy in Mallory-Weiss syndrome

We have carried out a retrospective review of 61 patients with Mallory-Weiss syndrome, 9 of whom underwent hemostatic injection treatment. At emergency endoscopy, 3 patients (5%) were actively bleeding and 6 (10%) had stigmata of recent hemorrhage. Fifty-two patients had a lesion of the cardia which was the suspected source of bleeding in 33 cases (54%). In the remaining 19 cases (31%) this site was not considered responsible because other sites of bleeding were present in the upper gastrointestinal tract. The 9 patients with active bleeding or stigmata of recent hemorrhage underwent injection treatment and the other 52 patients were treated with H2 antagonists. The low rebleed rate and the zero mortality recorded in this series indicate that endoscopy is the optimum method for diagnosis and treatment of patients with Mallory-Weiss syndrome.

Mallory-Weiss tear. A complication of cancer chemotherapy

Since the original report by Mallory and Weiss of tears in the lower esophagus or cardia of the stomach following alcoholic debauch, there have been many other cases, associated with sundry other causes, described in the literature. Recently, a Mallory-Weiss tear was reported in a patient as a complication of cancer chemotherapy. This article describes two similar cases and suggests that the Mallory-Weiss syndrome should be included in the differential diagnosis of any patient with epigastric pain, hematemesis, or melena after chemotherapy-induced retching or vomiting.

Mallory-Weiss syndrome. A study of 224 patients

With the increasing early use of endoscopy, Mallory-Weiss syndrome has been found to be the cause of upper gastrointestinal bleeding in 224 of 2,175 (10.3 percent) patients studied. Since Mallory-Weiss syndrome is a self-limiting disease in more than 90 percent of patients, conservative treatment, including multiple transfusion, electrocoagulation, and compression by a Sengstaken-Blakemore tube in descending order of use, is the treatment of choice, especially in the medically debilitated patient. The cirrhotic patient poses special difficulty and generally has a poor outcome no matter what the treatment. Prolapse of the stomach into the esophagus may be an etiologic factor in a small subgroup of patients.

Mallory-Weiss syndrome. Review of 69 cases

The records of patients treated for upper gastrointestinal bleeding from 1974 through 1978 were reviewed. Five percent of this group (69 patients) had bleeding due to the Mallory-Weiss syndrome. Only 36 percent of patients had a correct admitting diagnosis. Esophagogastroscopy proved the most reliable diagnostic tool, with 94 percent of 63 patients studied having the diagnosis of Mallory-Weiss laceration confirmed. Initial management was medical in all patients. Twenty-one patients (30 percent) required operative intervention. There was a good correlation between the transfusion requirement and the need for operation. There were two deaths in this series; both were considered preventable. The Mallory-Weiss syndrome is common. Esophagogastroscopy performed early can result in a diagnostic accuracy rate of greater than 90 percent. Aggressive nonsurgical therapy after early diagnosis should continue to reduce the role of operation in the treatment of this condition. However, if bleeding continues after initial medical management, or if bleeding continues after 1,500 ml of blood is required, then surgical therapy should be instituted without delay.

Mallory-Weiss syndrome in a 16-week-old infant

The Mallory-Weiss syndrome is a recognized cause of upper gastrointestinal bleeding in adults. It is a very rare entity in the pediatric age group. The case discussed outlines the reasons for its rarity and the modalities used for its diagnosis.

Mallory-Weiss syndrome. Evolution of diagnostic and therapeutic patterns over two decades

During a 19-year period ending December 1978, we treated 40 patients with upper gastrointestinal bleeding secondary to the Mallory-Weiss syndrome. Thirty patients had the triad of vomiting, hematemesis and alcoholism. The presence of lacerations within the gastric cardia was associated with the presence of hiatal hernia (p = 0.03). Endoscopic examinations demonstrated 32 of 38 additional upper gastrointestinal lesions associated with the syndrome that could have been mistaken as the actual source of hemorrhage. During the second decade, as compared with the first decade, widespread use of fiberoptic esophagogastroscopy led to the identification of the bleeding lacerations in 71% of the patients (versus 47% in the first decade) and in 80% (versus 0% in the first decade) of the patients who required an operation to control the bleeding. Although there was a 7.5% mortality rate in the two decades, the incidence of operative treatment tended to decrease (42-24%; p = 0.13). More impressive were the decreases in transfusions (14 units to 5 units per patient) and in delays before surgery (38 hours to 17 hours) (p equal to 0.05). Improved endoscopic diagnosis facilitates prompt and economic treatment.

Electrocoagulation of actively bleeding Mallory-Weiss tears

Thirty patients with upper gastrointestinal bleeding due to a Mallory-Weiss tear were diagnosed by endoscopy. Seventeen patients had stopped bleeding spontaneously, and 13 were actively bleeding when examined. Ten of these 13 were successfully electrocoagulated with cessation of bleeding without morbidity or mortality. Total cost and length of hospitalization were approximately one-third for those treated by electrocoagulation as compared to surgery. Endoscopic electrocoagulation of actively bleeding Mallory-Weiss tears is often successful and appears to be safe.